Doctors' Duty to Disclose Error: A Deontological or Kantian Ethical Analysis
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REVIEW ARTICLE
Doctors’ Duty to Disclose Error: A
Deontological or Kantian Ethical Analysis
Mark Bernstein, Barry Brown
ABSTRACT: Medical (surgical) error is being talked about more openly and besides being the subject
of retrospective reviews, is now the subject of prospective research. Disclosure of error has been a
difficult issue because of fear of embarrassment for doctors in the eyes of their peers, and fear of punitive
action by patients, consisting of medicolegal action and/or complaints to doctors’governing bodies. This
paper examines physicians’and surgeons’duty to disclose error, from an ethical standpoint; specifically
by applying the moral philosophical theory espoused by Immanuel Kant (ie. deontology). The purpose
of this discourse is to apply moral philosophical analysis to a delicate but important issue which will be
a matter all physicians and surgeons will have to confront, probably numerous times, in their
professional careers.
RÉSUMÉ: Le devoirdu médecin de déclarerses erreurs: une analyse éthique déontologique ou kantienne. On
parle plus ouvertement de l’erreur médicale (chirurgicale) qui fait l’objet de revues rétrospectives ainsi que
prospectives. Il s’agit d’un sujet délicat, à cause de la crainte d’entraîner une gêne vis-à-vis des pairs et des
représailles de la part des patients, que ce soit une action en justice et/ou une plainte auprès d’un organisme
professionnel. Cet article examine du point de vue éthique, à la lumière de la théorie philosophique morale
d’Immanuel Kant, c.-à-d. la déontologie, le devoir des médecins et des chirurgiens de déclarer leurs erreurs. Le but
de cet exposé est d’appliquer l’analyse philosophique morale à une question délicate et importante à laquelle chaque
médecin et chaque chirurgien devra probablement faire face à plusieurs reprises pendant sa carrière professionnelle.
Can. J. Neurol. Sci. 2004; 31: 169-174
Oliver Wendell Holmes, the American physician, poet, tools for minimising the occurrence of medical errors which
humorist, Dean of Harvard’s Medical School from 1847-1853, might contribute to such complications.
and father of the famous Supreme Court Justice, stated: “The Medical error has fairly recently become a topic of research
patient has no more right to all the truth than he has to all the and discussion.3,4,10-12 Recognition of errors and open discussion
medicine in the physician’s saddlebag…He should only get so of them by members of the health care team would be expected
much as is good for him”.1 Some physicians still feel this way,2 to help produce a culture less dominated by fear and
but both legal and bioethical thought have been steadily moving recrimination for making an error and therefore one conducive to
away from such a viewpoint and the trend has been toward an learning from them.
increase in the level of disclosure.1,3-7 We examine the duty of Error is an inherent feature of human behaviour, and
physicians and surgeons (focusing on the example of similarly, most complex systems such as the delivery of health
neurosurgeons) to disclose errors they have committed, from a care are subject to error. An attempt to understand and reduce
significantly less paternalistic perspective than that espoused by errors appears to be an obvious and integral component of
Holmes. An ethical analysis using the moral philosophy of quality assurance in health care delivery but open discussion of
Immanuel Kant, is used to support surgeons’moral responsibility error has not traditionally been encouraged or rewarded and has
to disclose error. hindered the progress of developing systems to minimize the
CONTEXT – M EDICAL ERROR
Reporting of adverse events (ie. complications) by health care
From the Division of Neurosurgery, Toronto Western Hospital, University Health
providers is essential, especially for surgeons, whose patients’ Network, (MB), Department of Philosophy (BB), and Joint Center for Bioethics (MB,
complications can result in dramatic and catastrophic BB), University of Toronto, Toronto, Ontario, Canada.
consequences for them.8,9 Furthermore, it is morally right and a RECEIVED JUNE 25, 2003. ACCEPTEDINFINALFORM NOVEMBER 17, 2003.
Reprint requests to: Mark Bernstein, Department of Surgery, University of Toronto,
moral obligation for health care professionals to openly Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst Street, 4W451,
recognize their fallibility and to attempt to develop strategies and Toronto, Ontario M5T2S8 Canada
THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES 169
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occurrence of error. In fact, many doctors have operated under a almost all are hidden (ie. not apparent to the patient). Many,
veil of fear at open disclosure of error; fear of punitive action by however, may negatively impact the system; for example delays
their superiors, fear of shame in the eyes of their peers, and fear prolong a surgical day which requires nurses to stay overtime to
of recrimination by patients in the form of legal action and/or a finish, and thus results in greater expenditures by the hospital.
complaint to the health care provider’s governing body.
One way to help eradicate the veil of fear and make DEONTOLOGICAL ETHICS: KANT’S MORAL PHILOSOPHY
discussion of error more transparent and acceptable is to study it Immanuel Kant was a German philosopher who spent most of
openly and prospectively. Currently, the first author is his life in Konigsberg, Prussia (1724-1804) where he studied
prospectively studying error in neurosurgery with respect to philosophy and physics. His writings contributed to the
incidence, type, severity, preventability, and impact on outcome, development of deontological moral theory which is one of the
and interesting data are accruing. 13 major theories at the foundation of modern medical bioethics.
We focus herein on the issue of disclosure of medical error by There are two main types of normative ethical systems:
doctors to patients, and examine this thorny issue from an ethical teleological or consequence-based, and deontological, or duty-
viewpoint using the moral philosophical theory espoused by based. The main teleological theory is utilitarianism, based
Immanuel Kant. primarily on the writings of the British philosophers Jeremy
Bentham and John Stuart Mill.14,15 The main deontological
DEFINITIONS – MEDICAL ERROR theory is that based on the writings of Immanuel Kant. Kant’s
For the purposes of this analysis we classify errors according writings on moral philosophy (just one component of his
to their severity (major vs minor), impact (bad outcome vs no writings) are translated in a number of volumes; the two main
bad outcome), and obviousness to the patient (obvious vs volumes we refer to are the Cambridge Edition16 and the
hidden). Examples from neurosurgical practice are used. Minor translation by H.J. Paton. 17 Everything that appears in quotation
errors with minimal impact on outcome are frequent while major marks is a direct quote from one of these volumes.
errors which result in bad outcomes are infrequent but not rare. We start to learn Kant’s moral philosophy in the Groundwork
of the Metaphysics of Morals (written in 1785). His main thesis
A. Serious, obvious error, bad outcome is that the moral worth of an act is not related to the outcome it
During surgery for an aneurysm in the brain, the wrong side brings but whether it is done from a sense of duty or obligation.
is exposed. The error is not recognized until significant brain Kant states: “The moral worth of an action does not lie in the
retraction and dissection has been done. The wound is closed and effect expected from it and so too does not lie in any principle of
the operation is then performed on the correct side. The patient action that needs to borrow its motive from this expected
awakens with a visible complication (eg. weak hand) related to effect”16(page 56); and “…though much may be done in
the wrong-side exposure. conformity with what duty commands, still it is always doubtful
whether it is really done from duty and therefore has moral
B. Serious, obvious error, no bad outcome worth”16(page 61). Duty is described as “that action to which
During surgery in the late evening for a large chronic subdural someone is bound”16(page 377). According to Kant “all duties
hematoma, the first bur hole is placed on the wrong side. The are either duties of right, that is, duties for which external
error is recognized after the dura is opened and no clot is found. lawgiving is possible, or duties of virtue, for which external
The wound is closed and the operation carried out on the correct lawgiving is not possible” 16(page 394-395).
side. The patient has an uneventful postoperative course. He goes on to define a categorical imperative. An imperative
C. Serious, hidden error, bad outcome is a command: “the representation of an objective principle,
insofar as it is necessitating for a will is called a command (of
A patient requiring a lumbar microsurgical discectomy for
reason), and the formula of the command is called an
intractable sciatica has a poor outcome, and postoperative
imperative”16(page 66). Categorical means unconditional: “that
imaging demonstrates that the wrong level was operated. A
which represented an action as objectively necessary of itself,
second surgery is required to properly treat the culprit disc
without reference to another end”16(page 67). He goes on to state
herniation.
that there is only a single categorical imperative, or
D. Serious, hidden error, no bad outcome unconditional command governing the morality of human
During surgery for a frontal brain tumor, while the bone flap behaviour and it is this: “act only on that maxim through which
is being fashioned, the high-speed drill plunges into the brain you can at the same time will that it should become a universal
producing a substantial brain contusion. The bone flap is law”17(page 29). He states it alternately: “…the supreme
removed, the contusion debrided, and the tumor successfully principle of the doctrine of morals is, therefore, act on a maxim
removed. The patient has a good outcome and is discharged which can also hold as a universal law…any maxim that does not
home the next day. so qualify is contrary to morals” 16(page 380). In other words, all
our acts must be such that they are universalizable to all other
E. Minor errors like situations and to all other moral agents (eg. doctors) so that
Minor errors are common and are lumped together for this to be moral, all human beings must act consistently and similarly
discussion. Examples include: 1) contamination of instruments in all cases.
causing a delay in surgery; 2) equipment failures causing further Kant puts the categorical imperative to the test by examining
delays; 3) minor technical mishaps which cause no significant the issue of the lying promise. He asks: “May I not, when I am
injury to tissue. Most cause no bad outcome for the patient and hard pressed, make a promise with the intention of not keeping
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it?”17(page 67). This relates directly to the dilemma of disclosure harmful to others in order to be repudiated;…the speaker may
of error as we shall see below. A surgeon might say: “There is even intend to achieve a really good end by it”16(page 553). By
really no substantive harm done, the patient might be more this statement it appears that Kant is categorical in his decrying
harmed if he/she knew, and I have a right to protect myself so I of the act of lying; there appear to be no exceptions. He proceeds
will lie.” Kant examines various scenarios and then concludes: to speak of imperfect duties to oneself and finally duties of virtue
“Should I really be content that my maxim (the maxim of getting to others, and vices that violate duties of respect, all of which are
out of a difficulty by a false promise) should hold as a universal pertinent to the discussion of disclosure of error.
law…? …I then become aware at once that I can indeed will to
lie, but I can by no means will a universal law of lying; for by DOCTORS’ DUTY TO DISCLOSE ERROR – KANTIAN ETHICAL
such a law there could properly be no promise at all…”17(page ANALYSIS
68). He is thus concluding that there can be no exceptions to the Let us examine the question of whether medical errors should
categorical imperative, and that lying is always wrong, but we be disclosed to patients, irrespective of whether or not they
will have occasion to revisit this below. produce a bad outcome, and whether or not they are obvious or
We are then introduced to the concept of the kingdom of ends, apparent to the patient.
in which every rational being must regard himself as giving In cases like A and B above (serious, obvious errors), to not
universal law through all the maxims of his will. “For, all rational disclose would require the telling of an obvious lie which would
beings stand under the law that each of them is to treat himself be unacceptable to Kantian ethics. Most patients would ask:
and all others never merely as means but always at the same time “Why are there two incisions on my head?” To not answer
as ends in themselves”16(page 83). This is our first clear exposure accurately would be to lie. Clearly it would be every doctor’s
to one of Kant’s central themes that all persons must be treated duty to report obvious and egregious errors to patients who
with respect. It is also an introduction to Kant’s concept of the would also, by circumstance, have some knowledge of the
autonomy of the will. In the kingdom of ends, Kant says, each existence of error because of obvious markers of the error (ie. an
person has a dual role; he is a sovereign or legislator and he is incision on the wrong side of the head). To not disclose this type
also a subject, obligated to obey the very rules he lays down as of error would require the surgeon to practice an act of obvious
sovereign. Thus Kant envisages a moral community as a group deception, the commission of a lie, the only purpose of which
of autonomous persons who prescribe for themselves the rules would be to serve only his own interests. “Thus a lie, defined
that they shall live by. merely as an intentionally untrue declaration to another, does not
We have now learned that we must behave out of a sense of require what jurists insist upon adding for their definition, that it
duty or obligation and not from any other motive. The duty or must harm another. For it always harms another, even if not
obligation, of course, is to do the right thing. Just what the right another individual, nevertheless humanity generally, inasmuch
thing is (and also what is morally wrong) is developed in Part I as it makes the source of right unusable”16(page 612); “…the
of The Metaphysics of Morals (written in 1797). Firstly, Kant duty of truthfulness….makes no distinction between persons to
reiterates his belief that an act cannot be right unless it is done whom one has this duty and those to whom one can exempt
from a sense of duty. “Adeed is right or wrong in general insofar oneself from it, since it is, instead an unconditional duty, which
as it conforms with duty or is contrary to it…a deed contrary to holds in all relations” 16(page 614).
duty is called a transgression”16(page 378). The first definition of There is nothing in Kant’s moral philosophy that would allow
a right Kant offers us is: “Right is therefore the sum of the for a surgeon attempting to hide this type of error from a patient.
conditions under which the choice of one can be united with the To reiterate Kant’s viewpoint, the duty not to lie is right strictly
choice of another in accordance with a universal law of freedom. because it conforms to a rule of conduct which meets the
Any action is right if it can coexist with everyone’s freedom in requirements of a supreme principle of duty, this principle of
accordance with a universal law…” 16(page 387). duty not being itself related to the production of a good
Kant believed there was only one innate right. “Freedom consequence. The moral rightness of an action does not consist
(independence from being constrained by another’s choice), in its being instrumental, directly or indirectly, in a good
insofar as it can coexist with the freedom of every other in outcome, but in its being a kind of action which all physicians
accordance with a universal law, is the only original right should perform as a matter of principle. The person of good will
belonging to every man by virtue of his humanity”16(page 393). not only acts in accordance with duty but he acts for the sake of
This was a most articulate and compelling statement of what we duty. This means that his sole motive for doing what is right is
refer to in modern bioethics as autonomy. his recognition of the fact that it is the right thing to do.
In Part II of The Metaphysics of Morals, Kant writes of virtue Furthermore, he does what is right because he is duty-bound to
and of duties of virtue. He describes perfect duties which are do so, and for no other reason and it must also be universalizable.
duties to perform (or abstain from performing) which are binding To revisit the lying promise: “And could I really say to myself
in all circumstances. Regarding the perfect duty to oneself to that everyone may make a false promise if he finds himself in a
abstain from lying, he states that “the greatest violation of a difficulty from which he can extricate himself in no other way? I
human being’s duty to himself…is the contrary of truthfulness, then become aware at once that I can indeed will to lie, but I can
lying. In the doctrine of right an intentional untruth is called a lie by no means will a universal law of lying”17(page 68). Thus Kant
only if it violates another’s right; but in ethics where no appears to categorically decry the act of active lying.
authorization is derived from harmlessness, it is clear of itself The same reasoning could obtain for cases like C and D above
that no intentional untruth in the expression of one’s thoughts can (serious, nonobvious errors) but there is a potentially
refuse this harsh name”16(page 552). “Lying…need not be fundamental difference in that the error is not obvious to the
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patient or family. Most people would contend that it is right for cannot be necessary at the same time…so a collision of duties
patients to have knowledge about significant errors that occurred and obligations is inconceivable. However, a subject may have,
during their treatment, even if they are not aware of them and in a rule he prescribes to himself, two grounds of
even if they were completely unintentional (as all medical errors obligation…When two such grounds conflict with each other,
are) and perhaps even not that preventable. If the patient asks practical philosophy says…that the stronger ground of obligation
“Did everything go well?” then to not disclose the error would be takes precedence”16(page 378-379).
to actively lie, a situation we have addressed above. But what In other words, if in a doctor’s opinion, disclosing an error
about patients who do not actually ask this question; what is the which the patient is not obviously aware of and the knowledge of
surgeon’s duty to disclose major error when an active lie would which might do more harm than good by the anxiety and lack of
not be required to conceal the full truth? confidence it might evoke, then perhaps the stronger ground of
One reason that common sense would suggest that reasonable obligation would reside in the not telling of the error and the
patients would wish to know about errors, is that patients would weaker ground of obligation would reside in the telling of the
need to know this information if they require another surgery, error. In this circumstance and based on this interpretation of
which is common in neurosurgery. For example, if a brain tumor Kant, the doctor would apparently be morally justified in not
recurs, the patient should have the requisite information to give disclosing the error. Furthermore, Kant may possibly leave an
fully informed consent for the second surgery. This would opening for us to use some discretion in passive lying, especially
include information which would allow the patient to decide in the situation of protecting others’ feelings and welfare. He
whether or not he wishes the same surgeon to operate or whether gives us some examples which might leave an opening for some
he wishes to find another surgeon who has no track record (for discretionary use of passive lying, depending on how we
that patient) of making errors. interpret. He speaks of an example in which an author inquires if
In a more immediate cause and effect scenario, if during the someone likes his work. If one does not like the author ’s writing
course of treatment an error occurs, then any follow-up treatment and hesitates in responding (apparently as he ponders the right
required to rectify the problem will require the disclosure of the thing to say or do) the author will interpret the slightest hesitation
shortcomings of the previous procedure. In order for a patient to as an insult. Kant concludes this discussion with the question:
properly consent to a follow-up treatment needed because the “May one, then, say what is expected of one?”16(page 554) but
first treatment included a medical mistake, the patient needs does not answer his own question, apparently leaving us to do so.
material information about what transpired during the first This could be liberally interpreted as Kant saying “Perhaps I
treatment including the fact that an error was made. If a surgeon don’t know for absolutely sure whether or not a passive lie to
has operated on the wrong lumbar disc, his explaining that: protect others could be morally justified and I will not commit
“There seems still to be compression of the nerve root and myself”.
further surgery is needed” would be inadequate disclosure, as As we have seen, a contravention on lying alone would not
opposed to: “I operated on the wrong level; would you like me allow us to moralize about all issues related to duty to disclose
to fix the problem or would you like another surgeon involved?” errors. Let us turn away from lying, and examine other tenets
So respect for the patient’s autonomy to make an informed within Kant’s writings to help us with the scenario of cases C and
decision for a second surgery, a central thesis in Kant’s writings, D in which active lying might not be required to conceal the full
would dictate that major errors be disclosed. However, the fact truth from a patient. One important platform of Kant’s
that the patient would benefit from the disclosure of errors, while philosophy relates to the issue of respect for people, which
making practical sense, is not germane to Kant’s philosophy. The would argue strongly in favour of informing them of information
simple fact that it is a doctor’s duty and moral obligation to do a reasonable person would wish to be informed of. He writes:
the right thing is the correct reason to disclose. Kant clearly “Every human being has a legitimate claim to respect from his
states that acts have moral content only if the action is done not fellow human beings and is in turn bound to respect every
from inclination but from duty. In other words, if a doctor is other”….he is under obligation to acknowledge, in a practical
inclined to disclose for whatever reason, this is insufficient in way, the dignity of humanity in every other human being. Hence
Kant’s thinking; the act must be done from a sense of duty or there rests on him a duty regarding the respect that must be
obligation in order to have moral worth. Furthermore, the shown to every other human being”16(page 579). Telling the truth
categorical imperative instructs that we all must disclose to all in an open, unforced manner surely would be considered highly
patients in all circumstances. respectful treatment of a patient, whether the information relates
What about the argument that disclosing a significant but to bad news, or to errors committed by accident in the course of
nonobvious error to a patient (like those described in cases C and trying to help the patient.
D) might produce more harm than good, in the sense that it might Another important discourse which is very pertinent to this
confuse and overwhelm the patient and fill him with doubt about discussion is Kant’s section entitled On the Human Being’s Duty
his care? This could add to the anxiety level of a patient already to Himself as His Own Innate Judge. He defines conscience as:
psychologically and physically burdened with a major illness “consciousness of an internal court…before which…a human
and having just undergone major surgery and could, therefore, being’s thoughts accuse or excuse one another. Every human
actually be seen as a maleficent act. Kant’s moral philosophy being has a conscience and finds himself…kept in awe (respect
was not absolute and inflexible; it may be interpreted as allowing coupled with fear) by an internal judge; and this authority
for compromise when conflicting duties arose. “But since duty watching over the law in him is not something that he himself
and obligation are concepts that express the objective practical (voluntarily) makes, but is something incorporated in his
necessity of certain actions and two rules opposed to each other being”16(page 560). He goes on to say that we all answer to our
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conscience which warns us before we make a decision, but he impact on outcome and who would be overly distraught and/or
does not specify what our conscience should dictate. We would could not properly comprehend the meaning of the error, it might
contend that conscience dictates that we disclose significant be more beneficient (or less maleficent) to not disclose. In fact
medical errors to our patients out of a sense of duty. there is an “escape clause” in Kant’s writings which provides for
Kant also speaks of several virtuous duties to others. Of different treatment of irrational beings (for example those with
beneficience he states: “…to promote according to one’s means psychiatric disease or altered congnition). He states: “…morality
the happiness of others in need, without hoping for something in is a law for us only as rational beings…”17(page 108) and
return, is everyone’s duty”16(page 572). Perhaps we would add “…duty…must therefore hold for all rational beings…”17(page
the words “for important information” after Kant’s word “need” 88). We also believe that minor errors do not generally need to
to relate beneficience to the act of disclosure of error. He speaks be disclosed to patients and while Kant’s writings do not
of gratitude as “…honoring a person because of a benefit he has specifically address the distinction between small and large lies,
rendered us”16(page 573). Patients would clearly qualify as for example, our “escape clause” here simply is an interpretation
deserving gratitude as they have certainly benefited us by giving of the practical aspects of Kant’s intentions. He writes: “...take a
us the greatest gift – that of their trust, and by providing us with step into the field of practical philosophy…about the correct
a means to exercise our skills and to earn our living. He also function of this principle in comparison with maxims based on
speaks of sympathetic feeling: “…while it is not in itself a duty need and inclination, in order that it may escape from the
to share the sufferings…of others, it is a duty to sympathize embarrassment of antagonistic claims…” 17(page 70). The
actively in their fate…”16(page 575). We believe that this methodology of studies that have examined this issue is
sympathy or empathy would argue in favour of sharing vital imperfect, but it appears that most patients wish full disclosure
information about errors with our patients. of errors that cause harm18 and the majority of patients may wish
Kant also speaks of vices which violate duties of respect for even minor errors to be disclosed.19
other human beings. The first and most important is arrogance, Kant actually makes a direct reference to the committal of
which is: “as it were, a solicitation on the part of one seeking errors from which we may be able to draw a direct inference on
honor for followers, whom he thinks he is entitled to treat with how we should treat our colleagues who err and how patients
contempt”16(page 581). We believe that secretively withholding should treat us health care providers when we err. He writes: “On
information about significant errors from our patients could be this is based a duty to respect a human being even in the logical
interpreted as representing the epitome of arrogance through use of his reason, a duty not to censure his errors by calling them
contemptuous behaviour. absurdities, poor judgement and so forth, but rather to suppose
Finally, let us return to Kant’s discussion of the kingdom of that his judgement must yet contain some truth and to seek this
ends, in which he states: “Act in such a way that you always out…and so by explaining to him the possibility of his having
treat…another person, never simply as a means, but always at the erred, to preserve his respect for his own understanding”16(page
same time as an end” 17(page 32). What is meant here is that it is 580). It sounds like Kant is advising us to be forgiving of those
acceptable to benefit from an interaction with someone as long who err and to learn from our mistakes, a lesson we could all
as that is not the sole motivation. For example, when a doctor is stand to learn, and a lesson which would revolutionize doctors’
reimbursed for services he performs for a patient, he is not attitudes about disclosing error if they felt that patients and peers
treating the patient only as a means to an end, but an end and a would be less judgmental of them if they disclosed more openly.
means. Withholding information about error from a patient is
treating him only as a means to an end, that of self-protection of CONCLUSIONS
the surgeon, self-aggrandisement, and avoidance of the possible
embarrassment associated with admitting to an error that might Kantian ethical theory has been extremely influential in the
be perceived negatively by the patient and/or the surgeon’s peers development of bioethical theory to guide the moral conduct of
and students. physicians and other members of the health care profession. It
Let us extrapolate a little further and explore what Kant is appears clear from analysis of his moral philosophical writings,
intending for such a kingdom. In such an ideal community as the that Kant would have strongly believed that all major errors
kingdom of ends, persons are not only autonomous but take accidentally befalling patients should be disclosed because the
responsibility for themselves and their actions and presumably physician is duty-bound to do the right thing. The right thing
would want to know about error if they were patients, and would includes not lying, respecting the patient’s dignity, acting with
wish to disclose error if they were doctors. In this kingdom, there beneficence, sympathy, gratitude, conscience, and without
is likely an implicit promise by doctors to patients to disclose arrogance, and never treating the patient as a means to an end.
major errors. Hence, making such a promise with no intent of One might interpret that Kant would allow withholding such
keeping it is a false promise, or a lie. Reneging on the promise information from a patient, if imparting that information would
by not disclosing would represent a breach of trust, contrary to be clearly judged to do more harm than good but, in fact, purists
the moral ideal of this community. If everyone routinely broke might not even grant this much discretion in Kant’s theses. These
promises it would make promise-making futile because no one views resonate with the modern views that are emerging on
would take them seriously. disclosure of error, in the medical, ethical, and legal literatures.
We have shown that according to the moral philosophical However not all the answers are in on this thorny issue, and
writings of Immanuel Kant, moral duty and obligation would further studies both of error itself and of disclosure of error are
dictate disclosing major medical error in the vast majority of needed.
cases. In selected patients in whom a major error has caused no When the first author was a resident, he recalls being told a
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maxim describing the “good doctor” in terms of possessing systems. J Law Med Ethics 2001; 29:346-368.
characteristics described as the three “As”: availability, 7. Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the
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